It means understanding the Murphy’s Law (If anything has to go wrong, it will go wrong) and taking extra measures to control and minimize the impact of those wrongs/failures.
Preparedness for damage control is a state of mental alertness to:
i. The possibility and probability of occurrence of a hazard
ii. Ready availability of a well rehearsed plan for spontaneous response
iii. Ready availability of trained manpower to spring to action
iv. Ready availability of equipment to contain the damages without any loss of time
v. Smooth and coordinated effort rather than chaotic individualism and inefficiency.
Preparation for damage control involves:
i. Proper planning
ii. Documented SOPs
iii. Periodic realistic rehearsals for various contingencies
iv. Identifying the ‘failure modes’ or ‘weak links’ in the chain of events and eliminating them
v. Repeated efforts at further refinement and perfection.
A crucial factor for success in damage control is the honest assessment of one’s weaknesses and honest efforts to convert them into one’s strengths. One has to achieve a stage of proficiency where every member of the team understands the importance of his contribution to the cause and is trained/ motivated enough to make that contribution on his own without any supervision or control.
2. Quality Management Tools Such as Six Sigma and Lean Thinking:
a. Application of Six Sigma for Elimination of Errors and Improvement of Safety:
Six Sigma developed originally at Motorola by Bill Smith, is a technique of process improvement by elimination of defects or variations.
It is a data driven approach and methodology that strives for near perfection (driving towards conformity standard of six SDs between the mean and the nearest specification limit) in any process related to production or service.
The term Sigma (the lower case Greek letter) is used to represent standard deviation (a measure of variation) and the Six Sigma Process is based on the notion that if one has six standard deviations between mean of a process and the nearest specification limit, there will be practically no items that fail to meet the specifications or predetermined standards.
The technique has been widely used in industry for eliminating the defects in product or service.
It can be applied to hospitals for ensuring safety of patients by eliminating errors, defects or deficiencies especially in the life threatening/risky procedures. Six Sigma is a mathematical data driven approach and requires organization wide training and acquisition of expertise.
It is being tried in some hospitals in western countries. In India, too, the technique has received a positive response in some hospitals.
However, the actual practical feasibility of its large scale application and beneficial effects in hospitals (especially in India) is yet to be proved.
b. Lean Thinking to Avoid Accidents:
Lean Manufacturing/Thinking, the concept developed by TAIICHI Ohno at Toyota is an effective tool for process improvement through waste elimination and value addition. However, the 5 S system of ‘Lean’ can also be useful in improving the safety level.
It is a simple concept that a messy workplace, desk or manufacturing cell makes it hard to find things, easier to get distracted and can cause accidents or mistakes. The 5 Ss stand for:
1. Sort: Sort the needed and unneeded items
2. Set in order: Arrange things in their proper places
3. Shine: Clean up the work place
4. Standardize: Standardize the first three Ss
5. Sustain: Make 5 S a part of the job
Visual aspect of the work place is the notable feature of Lean. Lean thinking is very visual and picturesque. Clean, clear and focused at the task at hand and nothing else. It does not require any mathematical analysis like Six Sigma.
Application of Lean in the Hospital Scenario:
The concept of Lean can be applied to hospital scenario also with a lot of benefits as seen from the experience of some hospitals. It can be applied to a lot of advantage in many departments such as A and E, OT, CSSD, leading to reduction of inventory costs, enhancement of employee satisfaction and safety and, most importantly—better serving the patient needs.
Through the use of simple visual management tools excellent results can be achieved such as:
1. Cleaning up the cluttered places in the A and E as well as OT by removing all the unused / unnecessary equipment/stores.
2. Redistributing the unused/idle equipment to other areas.
3. Freeing the space and making it easier for the staff as well as patients to move around quickly and safely with reduction of accident hazards.
4. Reduction in the inventory of stores and equipment by introducing, “Just-in-Time” concept.
5. Significant reduction of waiting time in the A and E by simplifying the patients’ sign-in process (registration).
6. A streamlined and efficient triage system for the patients.
7. Much decreased travel time for the nurses in the OT.
The concept can be applied to any other area of the hospital wherever there is any wastage of resources (ICU, lab, pharmacy, dietary service or manifold room, etc.), after a study and analysis of the operational system.
3. Restriction on Visitors:
Hospitals have a vast number of visitors (4-5 per patient) visiting the patients every day and every visitor brings along the dirt and infections from the street and adds up to the infections the patient may be having. That adds to the bio-burden that is very high as such in the hospital.
Added burden of infections in the environment does not go very well with the patients who already are sick and have over challenged body defenses, especially so in case of patients in ICU, NICU, ICCU, Neurology, ICU, Burns ward, patients on chemotherapy, suffering from AIDS or those in the postoperative ward.
It is, therefore, essential that the entry of visitors in the inpatient areas is regulated by fixing the visiting hours and the number of visitors allowed at a time. Normally, one hour in the morning and one hour in the evening may be adequate and not more than one visitor may be allowed at a time, besides a 24 hour attendant.
In critical care areas such as mentioned above, no attendants should be allowed inside.
There should be waiting area for the attendants where one patient per bed may be allowed to wait 24 hours. Inside the critical care area visitors may be allowed during the visiting hours, one at a time wearing the shoe cover and masks.
Since in India, visiting a patient admitted in hospital is considered an expression of solidarity and proof of caring for the individual in the hour of sickness, the average number of visitors per patient is much higher than in the western countries.
Often the visitors are uncooperative and become a nuisance when they try to hoodwink the security and flout the rules. It not only overtaxes the services, but overburdens the environment also with noise and infections. The security staff in the wards should keep an effective check and control over their entry.
It is advisable that during and up to an hour after the visiting hour, the rate of air change be stepped up to 10 to 15 per hour to clear off the pollution.
4. Restriction on Mobile Phones in the ICU/ICCU:
Mobile phones should not be allowed in the critical care areas at all. At least they must be switched off. Not only they cause interference with the functioning of electronic critical care equipment, but are also responsible for high noise pollution because people tend to lose control over volume while talking on the phone.
It may also be a prudent idea to muffle the sounds by acoustic treatment of the relative waiting area and canteen to cut down the noise level.
5. Restriction on Carrying Fire Arms/Other Weapons inside the Hospitals:
Instances have happened where relatives carried fire arms inside the wards and due to accidental/intentional fire, people got injured.
With the increase in terrorist activities and hospitals being soft targets, it is highly imperative to treat the hospitals as “No Weapon Zone” disallowing anyone from carrying fire arms / other weapons inside the hospital, except may be the police personnel on active duty.
The restriction should be duly notified through notices displayed prominently at the entry gates/lift lobbies, etc. and visitors should be made to pass through the metal detectors placed at the entry point.
Similarly, the vehicles entering the outer gate may be checked for any explosives or weapons.
Patients on the stretcher/trolley/wheel chair (who cannot pass through the metal detector) should be allowed entry through the open door to rush the emergency cases in. These patients may be checked by the doctors/nurses while examining them.
However, their attendants should be allowed to enter only through the metal detector and no laxity should be allowed in this matter.
Generally, visitors display less understanding and cooperation and show a lot of resentment in these matters. However, they should be informed about the requirement through notices/polite explanations by the security/other staff and the policy should be implemented without any exceptions because exceptions made, if any, always lead to resentment and arguments.
Actions to be taken in case of any Violation:
If any member of the staff, patient or public detects /suspects anyone carrying a fire arm/ other weapon inside the hospital premises, he/she should report the matter to the security officer/supervisor/any other senior staff giving details such as:
i. Description/Identification of the individual
ii. Place/location at which last seen in the hospital
iii. Description and possible location of weapon
iv. Reasons for suspicion that a firearm or other weapon may be present.
Actions to be taken by Security:
i. Locate and identify the individual
ii. Take him aside (preferably to security office) and politely inquire if he is carrying a weapon
iii. If the answer is in the affirmative
Politely inform him that fire arms/weapons are not allowed in the hospital Ask him to unload the weapon first then check the arms license
Note down the particulars of the individual, the weapon, ammunition, and license and politely escort him outside the hospital
If the answer is in the negative, (and there is a reasonable suspicion) the security officer may politely inform him of the suspicion and the need for security check of the person.
If the individual allows security check, then after recovery of the weapon:
The weapon should be unloaded
The details of the individual, weapon, ammunition and the weapon license noted down
The individual should be escorted out of the hospital.
If the individual resists/refuses security check or is unable to produce the license or the license is not in order then the security staff may have to overpower him, carefully recover the weapon and call the police to come and manage the situation.
Having taken all the above actions, the security officer should, report the matter to the MS and the safety committee for immediate investigation so as to find out how the weapon entered the hospital undetected and then take appropriate corrective measures.
These can be dangerous situations because nothing is known about the person, the weapon(s) or the purpose of bringing the weapon to the hospital. The security staff, therefore, should go in full strength and fully prepared to encircle and overpower the individual, in case he tries to resist or be violent.
6. Policy on Acceptance of Tests Done from Outside/Medicines Brought from Outside:
Investigations, drugs and food play an extremely important role in the treatment and recovery of patient and therefore, their high quality and reliability is a must. There is no way; the hospital can be sure of the quality of drugs or food brought by the patient/his relatives from outside.
Chances of spurious/adulterated drugs or deterioration of potency due to inappropriate storage conditions are always there.
Similarly, it may be difficult to establish the reliability of investigations done at an outside lab, unless it is a well known and reputed lab. And if the investigations are repeated by the hospital, it may mean doubling up the expenditure which no patient would like.
Generally, the hospitals do not accept medicines brought in from outside because of suspect quality as well as loss of own pharmacy sales. Outside food is also not allowed if the hospital has own dietary service. As regards the investigations, as a policy, the hospital may not accept them.
However, exceptions may be made on merits of the case. Therefore, the hospitals must have a well considered documented policy on acceptance of investigations done in an outside laboratory, medicines purchased from an outside chemist or the food brought in from home or market.
As regards, the concurrent use of other medicines that the patient might have been taking for some other disease, especially the Homeopathic, Ayurvedic, Unani or other medicines, it is in the best interest of the patient that he/she should fully explain the treating physician about all her diseases and the medicines he/she is on, so that the treating physician can take a overall correct view of the problems and decide what medicines the patient is going to be treated with while under his care.
Under no circumstance should the patient take any medicine, whatsoever, without the knowledge of and prescription by the physician. Any complications that may occur due to interaction of drugs, or any adverse/toxic effects, would entirely be the responsibility of the patient.
It would be prudent on the part of hospital to, as a standard practice, issue a written communication to the patient/his attendants, on admission, forbidding any self medication without the express approval of the treating physician.
7. Patients’ Information and Education about Safety:
Since a hospitalized patient is expected to stay in the hospital for some days, it is important to make him and his relatives comfortable by briefing them about the hospital, the policies and procedures, the system of functioning of staff and various services, the timings for various activities, etc. so as to get their full cooperation and make them feel at home. At the earliest after they reach the ward, the ward sister and the floor manager, while welcoming them, should brief them about the following essential aspects:
1. Orientation of the patient/his attendants:
The patients/their attendants need to be oriented towards the following essentials on arrival.
i. Room number, layout of the room and the ward layout
ii. Nurse call /Emergency call system to request assistance
iii. The location/operation of switches for lights, fans and AC
iv. Layouts of bathroom and fittings / fixtures (hot / cold water, use of grab bars) emergency call button, etc.
v. How to adjust the bed position
vi. Patient’s dress and the foot wear
vii. Patient identification bands, if in practice in the hospital. The identification band should ideally be tied around the right wrist (or the neck) of the patient immediately after admission and should be removed before discharge
viii.In case of new born babies identification bands bearing the CR number, mother’s name, date/time of birth and the infant’s sex are tied immediately (one each on left ankle and wrist) after first identification/birth. Another identification band is tied on the left ankle of the mother
ix. The meal timings and the choice of meals available
x. The timings for the house keeping services including the change of linen
xi. The timings for doctors ward rounds
xii. Procedure for payment of bills
xiii. Visiting hours, as applicable
xiv. The fire safety system including the escape routes
xv. The need to watch over and take care of their valuables such as mobile phone, watch, wallet, etc.
2. Making available a list of the important telephone numbers (sister’s duty station, doctor’s room, the treating physician, the NS, the security office, the maintenance service, the dietary/cafeteria service, the MS office) and the patient’s information brochure.
3. The important areas of the hospital, they may need to know such as, the Pathology lab, the Radiology department, the cashier and billing office, the security office, the cafeteria, the office of MS and the NS.
4. Procedure for reporting of any accidents/dangerous incidents (pertaining to patients, visitors or staff) to safety officer/security officer or for offering any suggestions.
5. The system of redressal of patient’s grievances.
6. Identification of staff on duty by the photo ID cards.
7. Activities to be avoided such as taking medicines/food items not prescribed by the physician.
Patients/their attendants also need to be advised about the things that are restricted/ prohibited and not to be done by them such as:
i. Bringing any eatables from outside
ii. Accepting any eatables form any strangers
iii. Taking any drugs other than those prescribed by the treating physician
iv. Bringing any medicines from outside the hospital unless required by the treating physician
v. Leaving vulnerable patients (old/infirm bed ridden, emotionally disturbed patient or a baby) alone. They should always be accompanied by an attendant. If no attendant is available then the hospital may provide one on request
vi. Entrusting valuables to the care of any stranger, even for a short while
vii. Visiting hazardous/restricted areas such as the terraces, the basements, the plant area, the manifold room, the diesel storage area, the radiology department, etc.
viii.Drinking, smoking or gambling in the hospital premises
ix. Leaving the ward/room without the permission of ward sister
x. Leaving the hospital without written permission of the treating physician and Medical Superintendent
xi. Using any electric appliances, heaters, etc. in the ward, if not permitted
xii. Letting the visitors stay in the ward/room in violation of the visiting rules
xiii. Causing inconvenience/disturbance to other patients by making noise.
xiv. Bringing any fire arms/other weapons in the hospital as they are prohibited.
Since safety and security can never be ensured without adequate knowledge, full cooperation and willing compliance with the safety rules by the patients and their relatives, they should be briefed fully about the system in place for ensuring their safety.
These aspects can be informed to the patients’/attendants best through a patient information brochure as well as personal briefing by the ward sister and the floor manager immediately on admission in the ward.
The brochure may also include information about any hazards in the area, the prevention/control measures and how best to avoid them.
The more the patients know about the place, the system of functioning, the rules and regulations, the safer and hazard-free will be their stay.
They should be encouraged to become informed members of their health care team and actively participate in the activities related to patient’s safety and wellbeing such as:
i. Asking any questions if they have about their health or safety
ii. Verify prior to any surgical/other procedure, the correct site/side of the body that is affected and is to be operated upon
iii. Remind the staff to check the patient’s ID band if the same is not checked before administration of medications/blood/blood products/taking blood samples or starting an invasive procedure
iv. Educating them about the safe usage of medications prescribed to them and their side/ toxic/after effects so as to inform the nurse for timely action, in case there are any adverse effects
v. Knowing and exercising the charter of patients’ rights and complying with the responsibilities enlisted therein.